Provider First Line Business Practice Location Address:
3857 KINGS HWY APT 1I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11234-2926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-258-7204
Provider Business Practice Location Address Fax Number:
718-692-0680
Provider Enumeration Date:
09/26/2025